Description: The patient is being referred for evaluation of diabetic retinopathy.
(Medical Transcription Sample Report)
MM/DD/YYYY

XYZ, M.D.

RE: ABCDOB: MM/DD/YYYY

Dear Dr. XYZ:

Thank you for your kind referral for patient ABC. The patient is being referred for evaluation of diabetic retinopathy. The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.

On examination, the patient is seeing 20/40 OD pinholing to 20/20. The vision in the left eye is 20/20 uncorrected. Applanation pressures are normal at 17 mmHg bilaterally. Visual fields are full to count fingers OU and there is no relative afferent pupillary defect. Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU. On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally. The macula, vessels, and periphery are also within normal limits.

In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time. We recommended him to have his eyes dilated once a year. I have advised him to follow up with you for his regular check-ups. Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.

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